Theory and Practice of Compounding Ointments
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COMPOUNDING FOR SCALP DISORDERS AND CONDITIONS Y. Pramar, Ph.D., Professor of Pharmaceutics Xavier University of Louisiana, College of Pharmacy, New Orleans, Louisiana. Goals: The goals of this article are to provide information on the physiology and disorders of the scalp, and typical drug therapy used to treat these disorders. Objectives: At the conclusion of this lesson, the reader should be able to: 1. Discuss the physiology of the scalp and the function of the sebum, sweat glands and pores. 2. List at least five disorders/conditions of the scalp. 3. Describe different treatment approaches used in scalp disorders. 4. Become familiar with various formulations used in the treatment of seborrheic dermatitis, dandruff, psoriasis, hair loss, lice and ringworm. Introduction Scalp disorders may be painful, annoying, unsightly and Pores: The pores in the skin are where the hair follicles embarrassing. Scalp problems may require short-term reside. The pore size is related to sebaceous gland size. treatment, but many of them need long-term therapy Pores enlarge to accommodate a greater oil flow. Acne over months, and sometimes years. Compounding caused by blocked pores often clears up when the pores pharmacists have a significant role in achieving enlarge allowing unimpeded movement of sebum successful therapeutic outcomes in this emerging field. through the pore. Anatomy and Physiology Sweat Glands: Sweat glands consist of a single tube, the The scalp consists primarily of the skin, sweat glands, lower portion of which is coiled into a ball and the upper sebaceous glands, hair shafts, and hair. When these part (the duct) opens onto the surface of the skin. There appendages are not functioning properly in harmony are two types of sweat glands, the eccrine and the with one another, various scalp disorders can occur. apocrine. The eccrine sweat glands, distributed all over the body, primarily regulate body temperature and Scalp: The scalp is the portion of the body consisting of eliminate toxic substances and waste products; the skin and subcutaneous tissue normally containing hair perspiration is clear and consists of traces of salt, that covers the neuro-cranium. It is especially rich in carbohydrates, protein and oil. The sweat they produce blood vessels; therefore, profuse bleeding may occur is primarily odorless. The apocrine sweat glands are with scalp injuries. The functions of the scalp (skin) primarily in the underarm area, around the nipples and in include protection and excretion. It secretes metabolic the genital area. They are stimulated by the same waste materials and toxins in order to rid the body of hormones that stimulate hair growth in the underarms them. It also secretes sweat to cool the body, and sebum and genital area. The fluid they secrete is milky and rich to protect the skin. in organic material that is subject to bacterial decay, causing body odor. The hair entraps both sweat and Skin: Each layer of the skin (epidermis, dermis, bacteria. subcutaneous) has a specific function. Included in the skin are the sebaceous glands that produce sebum and Sebum: When the sebum gets stuck in the pores, secrete it through the sebaceous ducts into hair follicles, whiteheads, blackheads, papules, pimples and cysts can where it migrates to the surface of the skin. This flow of ultimately occur. It is a result of the sebum getting sebum removes dead skin cells that flake off from inside blocked during its transport and clumping with dead skin the hair follicle. Sebum consists of fatty acids and other cells, being acted upon by bacteria and ultimately substances and protects the skin by reducing the blocking the opening to the skin surface. If pressure evaporation of water from the skin and blocks the builds up, pustules and cysts result. penetration of excess water into the skin. This sebum is one of two constituents making up the lipid film present Hair: Hair grows on the scalp and each hair filament on the skin surface, the other being the lipids of the originates in a deep hair follicle which penetrates into epidermal cells. the dermis. At the base of the follicle is the papilla which is the center of hair growth containing the capillaries and nerves that supply the hair. As new cells Treatment: The treatment selected for psoriasis of the are formed and older cells are pushed upward, they scalp is based on its extent and severity. Therapy can be gradually die and harden into a hair shaft, consisting of initiated using a corticosteroid preparation. Other two layers, the cuticle and cortex. The outer layer, the measures include tar preparations, such as coal tar cuticle, consists of flat, colorless, overlapping cells. The solution (LCD, Liquor Carbonis Detergens), anthralin, cortex contains pigment and a tough protein called calcipotriene and tazarotene. Treatment can be initiated keratin, forming the bulk of the hair shaft. Coarse hair, with a tar shampoo used daily. For thick scales on the as on the scalp, contains an additional inner core called scalp, a 6% salicylic acid gel, or a phenol : mineral oil : the medulla. The hair is lubricated by sebaceous glands glycerin mixture can be used. Alternatively, that are located in the hair follicle. In general, human fluocinolone acetonide 0.01% in oil can be applied under scalp hair is shed every two to four years; body hairs are a shower cap at night followed by tar shampoo in the shed more frequently. morning. Corticosteroids such as triamcinolone, fluocinolone, betamethasone dipropionate, fluocinonide, Hair growth: Hair growth is cyclical, consisting of three amcinonide, or clobetasol in solution form can be used phases. The growing phase is the “Anagen” phase; twice daily. about 90% of scalp hairs are in the anagen phase at any point in time. On a daily basis, about 50 to 100 scalp Hair Loss follicles go into the resting phase, or the “Catagen” I. Description: Pattern, or androgenetic baldness, is the phase, which involves 1% of the hairs daily. The most common form of alopecia. It is of genetic shedding phase is the “Telogen” phase and predetermination with the earliest changes occurring on approximately 10-20% of scalp hairs may be in the the front sides of the scalp and at the crown of the skull. telogen phase at any point in time. The extent of hair loss is variable and unpredictable, but may be experienced by approximately 80% of all men. SCALP DISORDERS AND THEIR TREATMENT Treatment: A 5% solution of minoxidil alone or in combination with other active ingredients can be used in Seborrheic Dermatitis and Dandruff both male and female patients, generally twice daily. Description: Seborrheic dermatitis is an acute or chronic Those that respond are usually less than five years into papulosquamous dermatitis presenting with dry scales their hair loss. and underlying erythema. In some cases pruritis is present. Dandruff occurs when there is a mild scaling II. Description: Alopecia areata is believed to be the without any erythema, and can occur if the scalp is dry result of an imuunologic process. Typically, there are or oily. It may be the result of several factors, including patches that are smooth, without scarring. Tiny hairs, hormonal imbalance, impaired metabolic nutrition, diet, generally 2-3 mm in length, may be seen. In some cases, tension, increased bacterial and fungal activity, all the scalp hair may eventually be involved. Alopecia biochemical changes in the scalp, the use of topical areata is a self-limiting disease where there may be medications and cosmetics. Seborrheic dermatitis complete re-growth of hair in about 80% of cases. In occurs when there is general erythema without tight, some cases, mild alopecia areata is resistant to therapy. thick, silvery scales. Psoriasis is evidenced by the presence of well-demarcated red plaques. Treatment: Severe forms may be treated by systemic corticosteroids; however, recurrences generally occur Treatment: Routine treatment for seborrhea of the scalp when therapy is discontinued. Corticosteroids can also involves a shampoo that may contain tar, zinc pyrithione be administered intralesionally; for example or selenium, used daily if necessary. A ketoconazole 1% triamcinolone acetonide 2.5 to 10 mg/mL can be injected or 2% shampoo can be used twice weekly. If needed, in aliquots of 0.1 mL every 1 to 2 cm in the involved solutions or lotions of topical corticosteroids can be used areas. The total dose should not exceed 30 mg per twice daily. month for adults. Another treatment includes daily use of anthralin 0.5% ointment. Psoriasis Description: Psoriasis is an inflammatory skin disease Other therapeutic approaches involve the use of topical that may be based upon a genetic predisposition. When diphenylcyclopropenone and squaric acid dibutyl ester. the skin is injured or irritated, it tends to induce lesions These agents serve to sensitize the skin; this is followed of psoriasis at the site. There are several variants of by application of progressively weaker concentrations psoriasis, with the most common being the plaque type. designed to produce a slight dermatitis. This results in Psoriasis presents as silvery scales on bright red, well- hair re-growth in 3 to 6 months in some patients. demarcated plaques that may be accompanied by itching. 2 III. Description: Drug-induced alopecia may result from Rx Hydrocortisone 1% Antipruritic Scalp Lotion thallium, excessive vitamin A, retinoids, antimitotic Hydrocortisone 1 g agents, anticoagulants, antithyroid drugs, oral Menthol 250 mg contraceptives, trimethadione, allopurinol, propranolol, Polysorbate 80 0.25 mL indomethacin, amphetamines, salicylates, gentamicin Ethanol 95% 25 mL and levodopa. Drug-induced alopecia is very Propylene glycol 25 mL disconcerting to the patient, but it is reversible when the Purified water, qs 100 mL causative agent is discontinued. Mix the hydrocortisone and menthol with the Treatment: No real treatment is indicated in such cases, Polysorbate 80.